Westminster at Home (Hospice)

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. DOCUMENT 1: Hand Hygiene Policy and Compliance Program Policy stated, in part: “Indications for staff performing hand hygiene are: before and after direct patient care”, and after any contact with contaminated materials.” CLINICAL RECORD 1/HOME VISIT 1 : This patient elected the hospice benefit on 09/24/2025 with a terminal diagnosis of cerebrovascular disease. During the home visit observation on 02/18/2026 with the hospice aide (Personnel Record 1) with the RN Team Leader (Personnel Record 5), the hospice aide was observed to give a bed bath to the patient. The hospice aide was observed to cleanse the patient’s rectal area and then reach up and touch her glasses without sanitizing her hands. During an interview conducted with the RN Clinical Team Leader on 02/18/2026 It was stated that the hospice aide did not follow the agency policy for hand hygiene.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 14 (21%) clinical record reviewed and in 1 of 3 (33%) home visit observations in which hospice aide services were provided, the agency did not ensure that written patient care instructions for the hospice aide prepared by the RN were specific and not generic. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit on 09/24/2024 with a terminal diagnosis of cerebrovascular disease. On 02/12/2026, the physician ordered wound care foam patch to left ankle bone and left foot for protection, and wound care add barrier cream to bottom daily and prn. The plan of care dated 02/12/2026-02/18/2026 ordered: “Aide 2x/week.” The hospice aide care plan dated 12/12/2025 assigned the hospice aide the relevant task of “bed bath at every visit.” The hospice aide care plan did not include instructions addressing the wound dressing on the foot should it become dislodged or wet during the bed bath. During the home visit on 02/18/2026 with the hospice aide (Personnel Record 1), the hospice aide was observed to provide the patient with personal care. A bandage was observed on the patient’s left foot. CLINICAL RECORD 3: This patient elected the hospice benefit on 12/22/2025 with a terminal diagnosis of pulmonary fibrosis. The RN initial visit note dated 12/22/2025 documented the patient was utilizing a walker and wheelchair. The Medical Social Worker assessment dated 12/30/2025 stated the patient used a transport chair through most of their home to help conserve energy. The plan of care dated 12/22/2025-02/18/2026 ordered: “Aide 2x/week.” The hospice aide care plan was reviewed for the dates of 12/22/-02/18/2026 and included directions to assist with transfer/ambulation every visit. There were no clear directions to use the transport chair/walker/wheelchair for transfers/ambulation. CLINICAL RECORD 7: This patient elected the hospice benefit on 02/06/2026 with a terminal diagnosis of lung cancer. The hospice plan of care was reviewed for the dates of 02/06/2026-02/18/2026 and included orders for hospice aide visits two times a week and the skilled nurse to wrap the legs with kerlix and ace bandages twice a week for edema. The hospice aide care plan was reviewed for the dates of 02/06/2026-02/18/2026 and assigned the HA the relevant task of a “bed bath at each visit”. The hospice aide care plan did not include instructions addressing the kerlix and ace bandages on the legs should they become dislodged or wet during the bed bath. An interview was conducted with the RN Clinical Leader (Personnel Record 5) on 02/18/2026 and it was stated that the hospice aide care plans needed to be more complete.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records in which the patient received hospice aide services, the agency did not ensure that the registered nurse was notified of changes related to the hospice aide care plan. CLINICAL RECORD 12: This patient elected the hospice benefit on 08/11/2025 with a terminal diagnosis of Alzheimer’s Disease. The hospice plan of care dated 11/09/2025-02/06/2026 included orders for hospice aide visits two times a week. The hospice aide visit note dated 02/04/2026 included documentation that the following tasks were not performed as directed by the hospice aide care plan dated 11/09/2025-02/06/2026: assist with dressing every visit, assist with feeding every visit, oral hygiene every visit, shampoo hair every visit, shower every visit, skin care-apply moisture barrier every visit, and skin care-apply lotion every visit. In review of the hospice aide visit note and the nursing notes, there was no documentation present that the registered nurse was notified of these changes to the hospice aid care plan. During the joint review of the clinical record and interview, the RN Clinical Team Leader (Personnel Record 5) stated that there was no documentation present that stated the registered nurse was updated that the hospice aide care plan was not followed.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A joint review of the agency report to the Governing Body dated 02/12/2026 with the Volunteer Coordinator on 02/18/2026 revealed that the volunteer utilization was 1.4% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview on 02/18/2026, the Administrator stated that there had been a change in the Volunteer Coordinator position to allow the agency to focus on re-building the volunteer program. A joint review of the agency report to the Governing Body dated 02/12/2026 with the Volunteer Coordinator on 02/18/2026 revealed that the volunteer utilization was 1.4% for the year of 2025, which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”